Interventional Radiology — MCQs
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Transjugular intrahepatic portosystemic shunt (TIPS) is contraindicated in which of the following conditions?
Uterine artery embolisation is done by using which of the following agents?
Judkins technique is used for which procedure?
Which of the following statements is FALSE regarding Transjugular Intrahepatic Portosystemic Shunts (TIPS)?
Therapeutic embolisation is indicated in all except?
What is a contraindication of TIPSS?
Which of the following statements are true about TIPS (Transjugular Intrahepatic Portosystemic Shunt)?
Compression of the carotid artery by a Glomus jugulare tumor is diagnosed by which imaging modality?
What is the indication for aortic stenting?
TIPSS involves percutaneous creation of a shunt between which of the following?
Interventional Radiology Indian Medical PG Practice Questions and MCQs
Question 1: Transjugular intrahepatic portosystemic shunt (TIPS) is contraindicated in which of the following conditions?
- A. Post-shunt encephalopathy
- B. Cirrhosis
- C. Portal vein thrombosis (Correct Answer)
- D. Variceal bleeding
Explanation: **Explanation:** **Transjugular Intrahepatic Portosystemic Shunt (TIPS)** is an interventional procedure where a shunt is created between the hepatic vein and the portal vein to reduce portal hypertension. **Why Portal Vein Thrombosis (PVT) is the correct answer:** The success of a TIPS procedure depends on the ability to access and pass a wire through the portal vein to establish the shunt. In cases of **extensive or cavernous portal vein thrombosis**, the target vessel is either occluded or replaced by small collateral vessels, making the procedure technically impossible or highly hazardous. While partial PVT is sometimes managed by experienced interventionists, complete PVT remains a classic **absolute contraindication** in standard practice. **Analysis of Incorrect Options:** * **Post-shunt encephalopathy (A):** This is a common **complication** of TIPS, not a contraindication for the initial procedure. However, pre-existing severe hepatic encephalopathy is a relative contraindication. * **Cirrhosis (B):** Cirrhosis with portal hypertension is the **primary indication** for TIPS (specifically for refractory ascites or variceal bleeding). * **Variceal bleeding (D):** This is a **major indication** for TIPS, especially when bleeding is refractory to endoscopic management (Rescue TIPS). **High-Yield Clinical Pearls for NEET-PG:** * **Absolute Contraindications:** Severe congestive heart failure (R-sided), severe pulmonary hypertension, and multiple hepatic cysts/polycystic liver disease. * **Relative Contraindications:** Active systemic infection, severe coagulopathy, and rapidly progressing hepatoma. * **MELD Score:** A MELD score >18 is associated with higher mortality post-TIPS. * **Mechanism:** TIPS bypasses the liver parenchyma, effectively converting sinusoidal portal hypertension into a side-to-side portocaval shunt.
Question 2: Uterine artery embolisation is done by using which of the following agents?
- A. Thrombin
- B. Polyvinyl alcohol (Correct Answer)
- C. Vitamin K
- D. Iodine
Explanation: **Explanation:** **Uterine Artery Embolization (UAE)** is a minimally invasive interventional radiology procedure primarily used for the treatment of symptomatic uterine fibroids and adenomyosis, as well as for controlling life-threatening postpartum hemorrhage. **Why Polyvinyl Alcohol (PVA) is correct:** The goal of UAE is to achieve permanent or semi-permanent occlusion of the small vessels supplying the fibroid, leading to ischemic necrosis while preserving the normal myometrium. **Polyvinyl Alcohol (PVA) particles** (typically 300–700 μm) are the gold standard embolic agents for this procedure. They are non-absorbable, biocompatible, and cause a mechanical block that triggers an inflammatory response and subsequent permanent vascular thrombosis. **Analysis of Incorrect Options:** * **Thrombin:** This is a potent procoagulant used primarily for the percutaneous treatment of **pseudoaneurysms** (e.g., femoral artery pseudoaneurysm) via direct injection. It is not used for distal embolization in UAE. * **Vitamin K:** This is a systemic medication used to reverse the effects of warfarin or treat Vitamin K deficiency. It has no role as a physical embolic agent in interventional radiology. * **Iodine:** Iodine is a component of **contrast media** used to visualize vessels during fluoroscopy. While essential for the procedure to guide the catheter, it does not possess embolic properties. **High-Yield Clinical Pearls for NEET-PG:** * **Access Site:** Usually the common femoral artery (trans-radial access is an emerging alternative). * **Other Embolic Agents:** Besides PVA, **Tris-acryl gelatin microspheres** are also commonly used. * **Temporary Embolization:** **Gelfoam** (absorbable gelatin sponge) is used when only temporary occlusion is needed, such as in acute trauma or certain cases of postpartum hemorrhage. * **Absolute Contraindications:** Pregnancy, active pelvic infection, and suspected uterine malignancy.
Question 3: Judkins technique is used for which procedure?
- A. Central venous line placement
- B. Coronary arteriography (Correct Answer)
- C. Renal angiography
- D. Chest tube insertion
Explanation: **Explanation:** The **Judkins technique** is the most widely used method for **coronary arteriography** (Option B). Developed by Melvin Judkins in the late 1960s, it involves a percutaneous femoral artery approach (Seldinger technique) using pre-shaped, specialized catheters. * **Why it is correct:** The technique utilizes specific **Judkins Left (JL)** and **Judkins Right (JR)** catheters. These catheters have unique secondary curves designed to naturally seek and engage the orifices of the left and right coronary arteries, respectively, with minimal manipulation. This makes the procedure highly reproducible and efficient for visualizing coronary anatomy. **Analysis of Incorrect Options:** * **Option A (Central venous line):** Usually performed via the internal jugular or subclavian vein using the Seldinger technique, but does not involve Judkins-specific catheters. * **Option C (Renal angiography):** While also an arterial procedure, it typically uses different catheter shapes, such as the **Cobra** or **RDC (Renal Double Curve)** catheters. * **Option D (Chest tube insertion):** This is a bedside surgical procedure (tube thoracostomy) for draining the pleural space and does not involve specialized angiographic catheters. **High-Yield Clinical Pearls for NEET-PG:** * **Sones Technique:** An older alternative to Judkins that uses a brachial artery cut-down approach and a single universal catheter. * **Amplatz Catheters:** Often used as a second-line choice if the Judkins catheters fail to engage the coronary ostia (especially in dilated aortas). * **Seldinger Technique:** The fundamental "needle-wire-sheath" method used to gain vascular access before any Judkins procedure begins.
Question 4: Which of the following statements is FALSE regarding Transjugular Intrahepatic Portosystemic Shunts (TIPS)?
- A. Shunt thrombosis is more common than shunt stenosis. (Correct Answer)
- B. Hepatic encephalopathy is a common complication.
- C. TIPS can improve ascites and hydrothorax.
- D. TIPS is more effective than variceal ligation for controlling bleeding.
Explanation: **Explanation:** **1. Why Option A is False (The Correct Answer):** In the context of TIPS, **shunt stenosis** is significantly more common than acute shunt thrombosis. Stenosis typically occurs due to **pseudointimal hyperplasia** (accumulation of collagen and fibroblasts) within the stent or at the outflow hepatic vein. While the use of PTFE-covered stents (e.g., Viatorr) has drastically reduced these rates compared to bare-metal stents, stenosis remains the primary cause of long-term shunt dysfunction. **2. Analysis of Other Options:** * **Option B:** Hepatic encephalopathy (HE) occurs in approximately 20–30% of patients. By diverting portal blood directly into the systemic circulation, the liver’s "first-pass" detoxification of ammonia is bypassed, leading to neurotoxicity. * **Option C:** TIPS reduces portal pressure, which addresses the underlying pathophysiology of refractory ascites and hepatic hydrothorax, often leading to significant clinical improvement. * **Option D:** Clinical trials consistently show that TIPS is superior to endoscopic variceal ligation (EVL) and pharmacological therapy in preventing re-bleeding, although it carries a higher risk of HE. **3. High-Yield Clinical Pearls for NEET-PG:** * **Primary Indication:** Refractory variceal bleeding and refractory ascites. * **Anatomy:** The shunt is most commonly created between the **Right Hepatic Vein** and the **Right Portal Vein**. * **Absolute Contraindications:** Severe congestive heart failure (due to sudden increase in venous return), severe pulmonary hypertension, and polycystic liver disease. * **MELD Score:** A high MELD score (>18) is a predictor of poor prognosis post-TIPS.
Question 5: Therapeutic embolisation is indicated in all except?
- A. Hemangioma
- B. Renal cell carcinoma
- C. AV fistula
- D. Aneurysms (Correct Answer)
Explanation: **Explanation:** The core principle of **therapeutic embolization** is the intentional occlusion of a blood vessel to stop hemorrhage, devitalize a tumor, or eliminate an abnormal vascular communication. **Why Aneurysms is the correct answer (The "Except"):** While interventional radiology is used to treat aneurysms, the goal is **exclusion** or **filling** of the aneurysmal sac (e.g., via endovascular coiling or flow-diverter stents) rather than "embolization" of the parent artery itself. Embolizing (blocking) the main artery supplying an aneurysm would lead to distal ischemia and infarction of the organ or tissue it supplies. Therefore, while "coiling" is a form of endovascular treatment, traditional therapeutic embolization is generally contraindicated for the parent vessel of an aneurysm. **Analysis of Incorrect Options:** * **Hemangioma:** Embolization is used to reduce the size of symptomatic or giant hemangiomas and to minimize intraoperative blood loss before surgical excision. * **Renal Cell Carcinoma (RCC):** Pre-operative embolization is a standard practice for large, vascular RCCs. It reduces intraoperative blood loss and "devitalizes" the tumor by cutting off its primary blood supply (usually the renal artery). * **AV Fistula:** Embolization is the treatment of choice for abnormal communications between arteries and veins. Agents like coils, glues (cyanoacrylate), or plugs are used to close the fistula tract directly. **NEET-PG High-Yield Pearls:** * **Common Embolizing Agents:** Gelfoam (temporary), Coils/Plugs (permanent), Polyvinyl Alcohol (PVA) particles, and Absolute Alcohol (sclerosant). * **Absolute Alcohol** is the agent of choice for **Arteriovenous Malformations (AVMs)**. * **Post-embolization Syndrome:** A common triad of pain, fever, and leukocytosis occurring after the procedure due to tissue ischemia/necrosis.
Question 6: What is a contraindication of TIPSS?
- A. Hepatic porto-splenic syndrome (HPS) (Correct Answer)
- B. Hepatorenal syndrome (HRS)
- C. Veno-occlusive disease (VOD)
- D. Budd-Chiari syndrome (BCS)
Explanation: **Explanation:** **Transjugular Intrahepatic Portosystemic Portosystemic Shunt (TIPSS)** is a procedure used to create a low-resistance channel between the portal vein and the hepatic vein to reduce portal hypertension. **Why Hepatic Porto-splenic (Hepatopulmonary) Syndrome (HPS) is a Contraindication:** HPS is characterized by intrapulmonary vascular dilatations leading to a right-to-left shunt and hypoxemia. TIPSS increases venous return to the right heart and subsequently increases pulmonary blood flow. In a patient with HPS, this exacerbates the intrapulmonary shunting, worsening hypoxemia and potentially leading to acute right heart failure. Therefore, severe HPS is considered a relative to absolute contraindication. **Analysis of Incorrect Options:** * **Hepatorenal Syndrome (HRS):** TIPSS is actually a **therapeutic indication** for Type 1 HRS. By reducing portal pressure, it improves systemic hemodynamics and renal perfusion. * **Veno-occlusive Disease (VOD):** Now often termed Sinusoidal Obstruction Syndrome (SOS), TIPSS can be used as a salvage therapy to decompress the liver in severe cases. * **Budd-Chiari Syndrome (BCS):** TIPSS is a **standard treatment** for BCS when medical management or angioplasty fails, as it bypasses the hepatic venous outflow obstruction. **High-Yield Clinical Pearls for NEET-PG:** * **Absolute Contraindications:** Congestive heart failure (Right-sided), severe pulmonary hypertension, polycystic liver disease, and uncontrolled systemic infection/sepsis. * **Relative Contraindications:** Hepatocellular carcinoma (HCC) obstructing the shunt path, severe coagulopathy, and HPS. * **MELD Score:** A MELD score >18-24 is associated with higher mortality post-TIPSS. * **Most Common Complication:** Hepatic encephalopathy (due to bypass of nitrogenous waste filtration).
Question 7: Which of the following statements are true about TIPS (Transjugular Intrahepatic Portosystemic Shunt)?
- A. It is a type of portocaval shunt.
- B. It is an intrahepatic shunt.
- C. It is performed by passing endoscopes.
- D. It is most suitable for patients going for liver transplant. (Correct Answer)
Explanation: **Explanation:** **TIPS (Transjugular Intrahepatic Portosystemic Shunt)** is a percutaneous procedure used to manage complications of portal hypertension, such as refractory ascites and variceal bleeding. **Why Option D is Correct:** TIPS is considered the "bridge to transplantation." Unlike surgical shunts, TIPS is performed via a minimally invasive vascular approach and does not involve entering the peritoneal cavity. This preserves the anatomy of the hepatic hilum and avoids the formation of dense surgical adhesions, which significantly reduces the technical difficulty and morbidity of a future liver transplant surgery. **Analysis of Incorrect Options:** * **Option A:** TIPS is a **Side-to-Side Portosystemic Shunt**, specifically connecting a branch of the **Portal Vein** (usually the right branch) to a **Hepatic Vein** (usually the right hepatic vein), which then drains into the IVC. It is not a direct portocaval shunt. * **Option B:** While the shunt itself is located within the liver parenchyma (intrahepatic), the term "intrahepatic shunt" is often used broadly. However, in the context of NEET-PG, the most clinically significant "true" statement regarding its utility is its role in transplant candidates. * **Option C:** TIPS is an **Interventional Radiology** procedure performed under fluoroscopic (X-ray) guidance using a transjugular venous approach. It is **not** an endoscopic procedure. **High-Yield Clinical Pearls for NEET-PG:** * **Route:** Internal Jugular Vein → Superior Vena Cava → Right Atrium → Inferior Vena Cava → Hepatic Vein → Portal Vein. * **Absolute Contraindications:** Severe congestive heart failure (due to sudden increase in venous return), severe pulmonary hypertension, and polycystic liver disease. * **Major Complication:** **Hepatic Encephalopathy** (occurs in ~25-30% of patients) because blood bypasses the liver's detoxification process. * **Primary Indication:** Refractory variceal bleeding and refractory ascites.
Question 8: Compression of the carotid artery by a Glomus jugulare tumor is diagnosed by which imaging modality?
- A. MR angiography (Correct Answer)
- B. CECT
- C. X-ray
- D. Jugular venography
Explanation: **Explanation:** **Glomus Jugulare** (Paraganglioma) is a highly vascular, slow-growing tumor arising from the jugular bulb. Because it originates in the skull base, it frequently involves the carotid canal and can encase or compress the internal carotid artery (ICA). **Why MR Angiography (MRA) is the correct answer:** MRA is the preferred non-invasive modality to assess the relationship between the tumor and the surrounding vasculature. It provides high-contrast resolution to differentiate the tumor mass from the vessel lumen. Specifically, it can demonstrate **arterial narrowing, displacement, or encasement** (the "Lyre sign" is more common in carotid body tumors, but vessel displacement is a hallmark here too). It helps in surgical planning by evaluating the patency of the ICA without the risks of ionizing radiation or iodinated contrast. **Analysis of Incorrect Options:** * **CECT:** While excellent for showing "moth-eaten" bone destruction of the jugular foramen, it lacks the precise flow-dynamics and vascular detail provided by MRA to specifically diagnose arterial compression. * **X-ray:** This is an obsolete modality for soft tissue or vascular assessment of the skull base. It cannot visualize the carotid artery or the tumor. * **Jugular Venography:** While historically used to show filling defects in the jugular vein, it does not provide information regarding the **carotid artery**, which is the focus of the question. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Sign:** On MRI, Glomus tumors show a **"Salt and Pepper" appearance** (Salt = subacute hemorrhage; Pepper = flow voids of high vascularity). * **Gold Standard:** Digital Subtraction Angiography (DSA) remains the gold standard for definitive vascular mapping and preoperative embolization. * **Clinical Presentation:** Pulsatile tinnitus and conductive hearing loss are the most common presenting symptoms. * **Phelps Sign:** Loss of the bony plate between the carotid canal and the jugular fossa seen on CT.
Question 9: What is the indication for aortic stenting?
- A. Acute aortic occlusion
- B. Aortic dissection (Correct Answer)
- C. Rheumatic aortitis
- D. Tetralogy of Fallot
Explanation: ### Explanation **Correct Answer: B. Aortic dissection** **Why it is correct:** In interventional radiology, endovascular aortic repair (EVAR) or thoracic endovascular aortic repair (TEVAR) using stents is a primary treatment modality for **Aortic Dissection**, particularly **Stanford Type B** dissections that are complicated (e.g., malperfusion syndrome, impending rupture, or persistent pain). The stent-graft serves to cover the primary intimal tear, redirecting blood flow into the true lumen and promoting thrombosis of the false lumen, thereby preventing aneurysmal expansion or rupture. **Analysis of Incorrect Options:** * **A. Acute aortic occlusion:** This is a surgical emergency often caused by a saddle embolus at the aortic bifurcation (Leriche syndrome). While catheter-directed thrombolysis or thrombectomy may be used, the primary management is usually surgical embolectomy (Fogarty catheter) rather than routine stenting. * **C. Rheumatic aortitis:** Rheumatic fever primarily affects the heart valves (mitral/aortic). While "aortitis" can occur in conditions like Takayasu arteritis or Syphilis, it is not a feature of Rheumatic heart disease. Inflammatory aortitis is managed medically (steroids/immunosuppressants) rather than with stents. * **D. Tetralogy of Fallot (ToF):** ToF is a congenital cyanotic heart disease characterized by VSD, pulmonary stenosis, overriding aorta, and RV hypertrophy. Treatment is surgical repair (Blalock-Taussig shunt or total correction), not aortic stenting. **High-Yield Clinical Pearls for NEET-PG:** * **Stanford Classification:** Type A involves the ascending aorta (Surgical emergency); Type B involves the descending aorta distal to the left subclavian artery (Medical/Endovascular management). * **Gold Standard Investigation:** For acute aortic dissection, **CT Angiography (CTA)** is the investigation of choice. * **TEVAR:** The primary goal of stenting in dissection is to "seal the entry tear." * **Coarctation of Aorta:** Another high-yield indication for aortic stenting in adults is post-ductal coarctation.
Question 10: TIPSS involves percutaneous creation of a shunt between which of the following?
- A. Portal vein and vena cava
- B. Portal vein and hepatic vein (Correct Answer)
- C. Hepatic vein and vena cava
- D. Portal vein and hepatic artery
Explanation: **Explanation:** **TIPS (Transjugular Intrahepatic Portosystemic Shunt)** is a percutaneous interventional procedure used primarily to manage complications of portal hypertension, such as refractory ascites and variceal bleeding. 1. **Why Option B is Correct:** The procedure involves gaining access via the **Internal Jugular Vein**, advancing a catheter through the Superior Vena Cava and Inferior Vena Cava into the **Hepatic Vein**. From there, a needle is used to puncture through the liver parenchyma to reach a branch of the **Portal Vein**. A stent is then deployed to create a low-resistance channel between these two systems, effectively shunting blood from the high-pressure portal circulation directly into the systemic circulation, bypassing the cirrhotic liver. 2. **Why Other Options are Incorrect:** * **Option A:** While the shunt eventually drains into the vena cava, the physical tract is created specifically between the portal and hepatic veins within the liver substance. * **Option C:** This describes the normal physiological drainage of the liver; no artificial shunt is needed here. * **Option D:** The hepatic artery carries oxygenated blood to the liver; shunting portal blood into it would not decompress the portal system. **High-Yield Clinical Pearls for NEET-PG:** * **Indications:** Refractory variceal bleeding (most common), refractory ascites, and Budd-Chiari syndrome. * **Contraindications:** Severe congestive heart failure (due to sudden increase in venous return), severe pulmonary hypertension, and multiple hepatic cysts. * **Major Complication:** **Hepatic Encephalopathy** (due to decreased detoxification of ammonia) and shunt stenosis. * **Goal:** To reduce the Portosystemic Pressure Gradient (PPG) to **<12 mmHg**.
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Vascular Access Techniques
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Angiography and Angioplasty
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Embolization Procedures
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Thrombolysis and Thrombectomy
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Transjugular Intrahepatic Portosystemic Shunt
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Biliary Interventions
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Genitourinary Interventions
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Gastrointestinal Interventions
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Percutaneous Biopsy Techniques
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Drainage Procedures
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Tumor Ablation Techniques
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Venous Interventions
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